Provider Demographics
NPI:1033854633
Name:HERMOSILLO, ROSA ALMA
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:ALMA
Last Name:HERMOSILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1098 E SAHARA AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-3220
Mailing Address - Country:US
Mailing Address - Phone:702-764-8639
Mailing Address - Fax:
Practice Address - Street 1:1098 E SAHARA AVE STE 103
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3220
Practice Address - Country:US
Practice Address - Phone:702-764-8639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVG68-0425553747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1578169702Medicaid